Social conditions in Sri Lanka accelerate spread of dengue fever

By Ajitha Gunarathna
5 December 2000

A dengue fever epidemic is causing widespread anxiety in Sri Lanka, particularly since the death of a doctor and a schoolgirl in Matara, 150 km south of Colombo. A number of students at the nearby Ruhunu University caught the disease, forcing the university to close indefinitely. The disease has since spread to several other districts, causing heavy casualties.

According to official figures, up to the end of May, 827 suspected dengue cases had been reported in Sri Lanka this year. By November 26, the figure had reached, 7,177, with 4,972 cases reported during November alone. Forty victims have died, with the worst-affected being children under 15 years of age. The casualty rate is the greatest since the disease was first reported in Sri Lanka in 1965, far higher than the previous record—last year's total of 1,699.

Dengue fever or dengue hemorrhagic fever is a viral disease carried by mosquitoes. The peak incidence of the disease is generally after the monsoon season, when the mosquito population increases because of the poor environmental and sanitation conditions in Sri Lanka.

It is impossible to obtain a full picture of the mosquito problem because no systematic mosquito control and research systems exist. But random surveys by the Medical Research Institute and the Anti Filarial Campaign have revealed breeding levels of the two main dengue-carrying mosquito species, Aedes Aegypti and Aedes Albopictus, far in excess of World Health Organisation risk guidelines.

One Colombo suburb, Boralesgamuwa, had a Breteau Index reading of 58 for Aedes Aegypti, compared to the usual Colombo city reading of 20. The WHO warns that a reading of more than 5 indicates a dengue risk and 50 signifies a high risk. In the Matara area, the readings were 15 for Aedes Aegypti and 53 for Aedes Albopictus.

According to a recent report, Sri Lankans have sought to avoid mosquito bites by burning 1,110 metric tons of mosquito coils worth 102.28 billion rupees up to August this year. Working class and rural poor families are worst affected. The wealthy minority lives comfortably in air-conditioned homes.

Although the media has expressed concern about the rapid spread of dengue, none of the reports have discussed the social conditions responsible—poverty, unplanned urbanisation driven by profit, poor sanitation and a drastically curtailed public health service.

Even in the main cities of Sri Lanka, uncovered garbage dumps, open pits and potholes filled with polluted water, stagnant canals and sewer channels are common sights. Many people live in shanties and slums, which are congested and lack sanitation. These areas are paradises for mosquitoes. Yet poverty-stricken people often cannot even afford mosquito nets to cover themselves while sleeping.

The Peoples Alliance (PA) government is seeking to blame ordinary people for the dengue epidemic. Newly appointed Health Minister W.J.M. Senewiratne has called on people to spend an hour a day cleaning up their surroundings. “Today's sad state is a direct result of people not participating actively to destroy mosquito breeding places and expecting others to take the initiative,” he said.

All the higher officials in the Health Ministry are repeating the same message. Moreover, education authorities in Matara area kept 46 schools closed for two days so that school children could participate in “voluntary” cleaning up programs.

Clearly, the government is trying to wash its hands of any responsibility. On November 6, the government-controlled National TV Corporation reported that the authorities would take legal action against the occupants of housing units and institutions that allowed mosquito-breeding places around them.

Although hundreds of cases of dengue have been reported and dozens have died annually since 1989, neither the former United National Party (UNP) government nor the PA, which came to office in 1994, have developed a dengue control and research program. They have simply appointed committees and special taskforces during epidemics in order to appease the public.

Dr. Kolitha Sellahewa, president of the Ceylon College of Physicians, told the WSWS: “If the environment is kept unpolluted, not only dengue but malaria, filaria, rabies and most of the other communicable diseases, can be eliminated. Unfortunately here we don't have such an environment. Unplanned urbanisation, without providing the proper infrastructure and a genuine preventive medical service, has created a series of epidemics in this country.”

When the latest dengue outbreak erupted, some local governments—municipal and local councils—faced protests and admitted that they did not have enough garbage compactors or other collection vehicles and were unable to employ the staff needed to clean up the environment.

Villagers from Madiwela on the outskirts of Colombo marched to the local council on November 6, demanding the immediate closure of the council's open garbage dump. They called on the council to cleanse the area where two dengue deaths have already occurred and several other dengue cases have been found.

Madiwela villager, Upul Hemantha, whose son died from dengue last month, told the WSWS: “The government asks us to clean mosquito breeding places in our own premises. But the government and the local council pollute the environment by dumping garbage in our village. This is why several dengue patients were found in this area, with two deaths including my son.”

Students and teachers of Sri Sangananda Vidyalaya in Weligama, a southern coastal village, demonstrated with placards calling on the authorities to shift the council garbage dump in front of their school.

The Government Entomological Assistants Union, whose members study insects and their links to disease, says it warned the government last September about a spread of dengue mosquitoes to the south of the island, but no action was taken and dengue had reached epidemic proportions nationally as a result.

Health and preventative services fail

Most Sri Lankan hospitals do not have the intensive care facilities needed to care for dengue patients. Where intensive care units do exist, in a few major hospitals, they are always overflowing with seriously-ill patients.

Upul Hemantha spoke of his son's treatment. “My son was in a critical condition in ward 4 in Lady Ridgeway Hospital—the main pediatric hospital. The ward staff tried their best to save my child. They also booked an intensive care bed. But my son was given a bed only six hours before his death. It is tragic that there aren't enough intensive care unit beds in the hospital where critically-ill patients are transferred from all over the island.”

Moreover, only a few hospitals have the blood and platelet transfusion facilities required by dengue patients. Dr. Jayalath Bulathge, deputy director of the Kurunegala teaching hospital, told Dinamina, a Sinhala daily, that the hospital lacked fresh blood and platelets. He added that the authorities had not taken immediate action to curb the disease.

Early detection of dengue is important to minimise fatalities. Dengue can be clinically suspected or diagnosed, but it is difficult to treat the disease without reliable laboratory investigations. A senior consultant physician at the National Hospital of Sri Lanka told the WSWS: “One of the biggest problems is that we don't have enough blood investigation facilities. Therefore we are forced to ask patients to obtain Full Blood Count (FBC) and dengue serology tests from outside laboratories.”

Several National Hospital nurses complained that they were not provided with enough blood collecting bottles for FBC tests, even though scores of dengue patients were admitted to their wards during the recent outbreak.

The laboratory manager of the Asiri Hospital, a Colombo private hospital, admitted that the number of dengue confirmation and FBC tests had risen sharply in his institution. Asiri charges 850 rupees ($US10.50) for a dengue serology test and 125 rupees ($US1.54) for a FBC test.

Using older and cheaper tests for dengue, the government Medical Research Institute takes more than two weeks to issue reports while Asiri does so within four hours. The National Hospital can perform only 200 FBC tests per day and 50 per night due to the acute shortage of medical laboratory technologists and lack of equipment, according to Saman Jayasekera, secretary of the technologists' union.

A technologist working in the Matara General Hospital told the WSWS: “We have to work for 24 hours without a break. Our workload has increased 10-fold. We have requested more technologists from the health authorities but we have not received any. The hematology section has only six technologists. Even without an epidemic we couldn't manage.”

Government funding cuts mean that hospitals cannot take even the most elementary precautions. The transmission of the dengue virus within the hospitals could be minimised by covering patients with mosquito nets. Yet this simple procedure is not used in most hospitals.

The World Health Organisation has recommended an advanced preventive program to curb dengue in Sri Lanka but this is a pipe dream because of spending cuts as a result of IMF and World Bank directives. Government expenditure on health services has fallen from 2.3 percent of the Gross National Product in 1989 to 1.4 percent. Of that total only 15.3 percent is allocated to community health services. As a result, there are few epidemiologists and entomologists.

The government has tried to cover over the latest crisis by shifting public health inspectors, doctors and other health workers to the Matara area from various other campaigns and institutions. With them have gone mosquito spraying (“fogging”) machines and an old blood-testing machine no longer used by the National Hospital.

The latest dengue epidemic, on top of continuing outbreaks of cholera, measles, malaria, hepatitis and leptospiroses, shows that Sri Lankan governments are increasingly neither willing nor able to provide a genuine preventive service to curb communicable diseases.